NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
Question 2 of 5
A client has returned from having a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
Correct Answer: B
Rationale: Bright red urine with many clots indicates significant bleeding post-prostatectomy, requiring immediate reporting. Normal output is 40-50 mL/hour, dark red urine with few clots is expected, and pain med requests are routine.
Question 3 of 5
The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the functioning of the client's recent memory?
Correct Answer: C
Rationale: I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen. This tests immediate recall, a component of recent memory.
Question 4 of 5
A diabetic client has been maintained on Glucophage (metformin) for regulation of his blood glucose levels. Which teaching should be included in the plan of care?
Correct Answer: A
Rationale: Metformin can affect kidney function, so changes in urinary patterns should be reported. Optimal effects occur sooner than six weeks , carbohydrates should be balanced, not increased , and itching is not a common side effect .
Question 5 of 5
Following a coronary artery bypass, a client develops a temperature of 102°. The nurse should notify the doctor because an elevation in temperature:
Correct Answer: B
Rationale: A fever increases metabolic demand, which can decrease cardiac output in a post-bypass patient, potentially straining the heart.